Salvage of a Misplaced Hickman Catheter: A New Endovascular Technique

Abstract

for the same purpose and, in more than 200 insertions, have not had to revert to the use of the peel-away sheath. We also begin with micropuncture access but, after insertion of the micropuncture coaxial dilator, an introducer sheath, 5.5 F or larger, is inserted. The tunnelling is carried out in the same manner but, at this stage, we insert two guide wires through the sheath, which is then removed. We prefer a hydrophilic wire and find the Radiofocus Stiff Type (Terumo; Tokyo, Japan) most suitable. Dilation of the venous puncture is performed only to 14 F (in almost all cases) over either wire. After removal of the 14-F dilator and while digitally compressing the venous puncture site, the back ends of both wires are inserted into the distal ends of the split catheter and brought out from the proximal ends. While grasping both wires at their proximal exit, the catheter may now be inserted into the internal jugular vein (usually with slight resistance on introduction of each side of the catheter, ensuring a snug fit and lack of venepuncture bleeding) and placed with ease in the desired central position, after which the guide wires are removed and the procedure is finished in the standard fashion. Our technique has the following advantages in addition to those described by Patel et al (1): 1. The insertion of the two wires into the two sides of the split catheter is an extremely simple maneuver; 2. The presence of two wires has allowed insertion of the catheter without the peel-away sheath in all our cases so far, with resistance caused by extensive scarring or other factors necessitating further venepuncture dilatation to 16 F in rare cases; 3. When a left-sided approach is necessary, we use a longer introducer sheath (usually 24 cm), which is placed in the superior vena cava, allowing placement of both guide wires in the superior vena cava; the catheter easily follows both wires around the angles formed with the left brachiocephalic vein without a tendency to buckle or turn superiorly at the junction with the superior vena cava. Nothing comes without a price; this technique necessitates a guide wire and introducer sheath that the procedure of Patel et al (1) does not, but we believe the advantages gained are worth it.